K. SRINIVASAN, DPM., MD., Professor, Department of Psychiatry, St. John's Medical College Hospital, Sarjapur Road, Bangalore-560034.
Indian J Psychiatry. 2000 Oct;42(4):393-6.
We reviewed the case records of patients admitted to the medical, surgical and orthopaedic wards of a teaching general hospital to see whether junior doctors took an adequate drinking history from their patients. Results showed that in more than 50% of the case sheets examined, the resident doctors failed to document any details regarding alcohol consumption. Pattern of drinking was mentioned in 14% of the case records. Few case sheets carried details of alcohol related problems. Overall, interns were better than post-graduate students at documenting details of alcohol consumption among their patients. The junior doctors did not identify harmful drinking in 43% of their patients.
我们复习了在一所教学医院内科、外科和矫形科病房住院患者的病历，以观察初级医生是否向他们的患者询问了充分的饮酒史。结果表明，在所检查的病历中，有 50%以上的病历中，住院医生未记录任何关于饮酒的详细情况。有 14%的病历中提到了饮酒方式。只有少数病历记录了与酒精有关问题的详细情况。总的来说，实习医生比研究生更善于记录他们的患者饮酒情况的详细信息。初级医生没有发现他们的 43%的患者存在有害饮酒。
